Dr Dace's useful links
Bookmark this handy page!
Quick clinical look-up and patient leaflets
- www.patient.co.uk: patient information leaflets and physician lookup; superior in my opinion to www.gpnotebook.co.uk;
- www.dermnet.org.nz - excellent dermatology web site from New Zealand.
Medications
- MIMS - manufacturers' prescribing information, including foreign names of drugs, plus clinical calculators including a very good cardiac risk calculator (free resource);
- www.drugwatch.com - an informative US web site listing medications and their indications, side effects etc.
Guidance on medical certification
- Fitness for work after surgery - a useful resource of evidence-based and consensus-based guidance on expected time off work after various types of surgery.
- www.dwp.gov.uk: official guidance on issuing medical certificates under the NHS.
- www.dvla.gov.uk: medical aspects of fitness to drive - at a glance guide for doctors (link updated 18.10.2007).
Clinical evidence
- bandolier (updated link): free, scholarly, entertaining, well-written, searchable clinical evidence: the vanguard of evidence-based medicine;
- Cochrane reviews: an authoritative source of medical evidence;
- NICE: National Institute for Health and Clinical Excellence - well designed web site where it is easy to find the guidance paper you are looking for;
- www.clinicalevidence.com: clinical evidence from the BMJ group, no longer free;
Prostate cancer
- prostate cancer guidance: Useful summary sheet for advising men about testing for prostate cancer. Arguably in symptomless males the risks of this test outweigh the benefits.
Obstetrics and gynaecology
- Gynaecology update from Mr T. M. Malak, Consultant Obstetrician and Gynaecologist. Much useful reference material, including a very useful paper on PCOS, a topic that seems to cause a lot of confusion.
- Does it drive you nuts every time a pregnant patient comes with a request for iron tablets from the midwife, when almost always her haemoglobin is normal for pregnancy? This publication on Antenatal care from the National Institute for Clinical Excellence (NICE) backs my many years' resistance to prescribing iron tablets to pregnant women with physiologically lowered haemoglobin. This is not new and it's basic stuff. See section 8.1 for details. If anaemia is suspected you need to find out why (check for thallassaemia trait, check the ferritin), not just prescribe iron, which may do harm.
QOF reference
- eGFR calculator with a link to CKD management guide, or you may prefer to go straight to the full UK Chronic Kidney Disease guidelines from www.renal.org. "CKD is both much more common and more important than previously recognised."
- About the PHQ-9 depression questionnaire here. Click to download PHQ-9 here. This questionnaire is designed and validated for the patient to fill in on their own. It is not validated to be used during a consultation. Better to ask the patient to bring it back completed at the follow-up visit. PHQ-9 is not a diagnostic tool, it is a screening test. Use your clinical judgement and don't let some bogus number de-skill you.
Other reference
- www.nelh.nhs.uk: a wealth of handy clinical resources;
- British Medical Journal;
- www.univadis.co.uk - including an illustrated anatomy database (free resource - registered doctors' access only).
Dental emergencies
- Common dental emergencies: article from the American Family Physician: think it's ok to give antibiotics for toothache? Sometimes yes, sometimes no. We don't know, we're not dentists. Send the patient to a proper dentist. Our job includes giving a prescription for suitable analgesia. It doesn't include doing a job we have no training in. Would you treat someone's cat because the GP is cheaper than going to the vet? Of course not...
Quackery
- www.badscience.net: Dr Ben Goldacre's columns from the Guardian on the misrepresentation of science and medicine in the media. Check out this delightful article about detox for example;
- I am not so happy with the little black duck at www.quackometer.net. The quackometer is an experiment to see if it is easy to spot quack web sites just from the language they use, however it gave a score of 10 canards to my sister's hypnotherapy web site at www.keyhypnotherapy.co.uk, which seems unfair because she says Clients will always be encouraged to follow the advice of their GP or hospital consultant. What's more that little duck is advertising ear candles. I never got a response from the owner of the site;
- why homeopathy is bunk: a simple challenge to homeopaths;
- www.quackwatch.org: nonprofit corporation whose purpose is to combat health-related frauds, myths, fads, and fallacies. Useful for when your patients ask you about the latest plausible scam that you haven't heard of;
- skepdic.com: guide to rational thought about extraordinary claims, including an alternative medicine section;
Vitamin supplements
Think about it. Vitamins are not magic pills. They have a correct place in the management of genuine deficiencies, in prevention of neural tube defects during the first trimester of pregnancy and in one or two other areas (all those well-covered ladies with dark skins who complain constantly of aches and pains probably need their vitamin D levels checking).
Vitamins are co-enzymes. There are many reversible biochemical reactions taking place in the body in which the presence (or absence) of a co-enzyme will tip the balance in favour of one substance or another being produced. More of this, less of that. Sometimes the body needs this, sometimes that. Are we so clever that we can interfere with this balance without having the faintest idea of all those millions of processes going on inside our bodies? That is New Age hubris.
Our only hope is to do our best to interpret the best available evidence. Hippocrates himself disparaged reliance on imaginary theory at the expense of actual observation.
Except when we have evidence to the contrary, I think it is reasonable not to interfere with the natural processes of our bodies.
- http://www.library.nhs.uk/: article on the recent research suggesting that vitamin supplements may damage health. Some is good so more must be better, right? Wrong. I suggest instead: learn to cook and use fresh ingredients.
- Cochrane library: more evidence here.
- More on vitamins from the peer review journals Archives of Internal Medicine and Journal of the American Medical Association: older women vitamin poppers die younger, and healthy men have an increased risk of prostate cancer risk associated with vitamin E supplements.
Combatting abuse
- NHS zero tolerance: Health Service Circular with guidance on dealing with abuse to NHS staff.
Links explaining that you don't have to do every piece of unnecessary paperwork
- hospital medical certificates: hospital doctors must issue appropriate certificates and not expect post-op or fracture clinic patients to pitch up at the GP the next day just to get a Med3.
- GANFYD: which stands for "Get A Note Form Your Doctor." A helpful essay on how to deflect inappropriate requests for certificates and medical reports. Includes the downloadable universal GANFYD deflector form. (You can of course also charge a fee - this usually causes the requester to realise that the report wasn't necessary after all.)
- Reducing GP Paperwork a government red paper issued in about 2001. This was an official document published by the Cabinet Office, with a foreword by Tony Blair. The original link no longer leads to the document, which has been hidden somewhere else. However using the Wayback machine I have retrieved it, and you can download it from the link given.
Among the things GPs officially do not have to do are:- write sick certificates for patients just discharged from hospital - this is the responsibility of the hospital doctor;
- counter-sign passport applications;
- issue repeat prescriptions for gluten-free foods;
- counter-sign driving licence applications;
- record injuries for police purposes (this is the job of the Forensic Medical Examiner (FME, Police Surgeon);
- provide jurors with a certificate to excuse them from jury service;
- counter-sign shotgun certificate applications;
- sign the statement at part 1 of Attendance Allowance or Disability Allowance application forms;
- provide patients with a certificate to explain a short-term absence from an attendance centre.
Note that many of these certificates and letters fall outside the GP contract, and if you do them you are entitled to charge. A simple procedure is to advise patients requesting these things to write in their own words to the authority that is requesting the information, giving permission to approach the GP if necessary. Then, if the work is requested, the fee can be agreed in advance with the authority concerned (note that there are no "BMA" fees - you set your own fees).
More time-wasting - multiple prescriptions for dosette boxes
Why do GPs have to print and sign four lots of prescriptions for a patient when one would do? Well they don't.
The argument is that the extra time taken by the pharmacist to dispense medications in dosette boxes instead of bottles has to be paid for (reasonable enough) and therefore the GP should spend their time unpaid (unreasonable) to check and sign weekly prescriptions instead of monthly ones. This way the pharmacist gets paid four lots of dispensing fees for one dispensing activity (making up four dosette boxes).
However, this is wrong for a number of reasons.
Firstly, the GPs' time would be better spent thinking carefully about the patient's medication rather than signing multiple scripts, of which there may be many. This is ultimately a safety issue.
Secondly, pharmacists are already paid for this service in their existing contract. To quote from guidance from Oxfordshire PCT, With the new [2005 pharmacy] contract, additional funding was made available for community pharmacies in order that they could meet their obligation under the Disability Discrimination Act (DDA) which in some situations included the provision of an MDS. The guidance from Wessex LMC goes further and states that The pharmacists invest time into this and there has been a temptation to ask the GP to do four seven day prescriptions per month. This allows additional funds to be earned to cover the pharmacist costs. It is our view that this is an incorrect funding stream and some people within the Health Service would view at as fraudulent. Our advice is to think about what is best for your patient. Your pharmacist has a duty to consider the patient's need and supply medication appropriately. There is similar guidance from Yorkshire PCT and Hampshire.
Thirdly, as already stated, pharmacists have an obligation under the Disability Discrimination Act to dispense in compliance aids if this is necessary (rather than merely convenient) for the patient. Failure to do this where appropriate would be a breach of the law. The law is summarised on the Pharmaceutical Services Negotiating Committee web site.
Local medical links
- www.lmc.org.uk: London Local Medical Committees.
For locums and those looking for locums
If I cannot help you, please click on www.locum123.com for locums nationally. You can also advertise your vacancy on www.lmc.org.uk, the London LMC web site.
How cool is that?
archive.coull.net/advice: Robbie Coull's advice for locums. This is an archived site - Dr Coull doesn't appear to have updated it recently. I'd still recommend you have a look. Click for Dr Coull's Locum Survival Guide.
Wizard wheezes
- www.tvbgone.com: a handy gadget for turning off annoying TVs on house calls while trying to listen to little Johnny's chest.
Disclaimer
The links on this page are to external websites over which I have no control and for which I take no responsibility.
- Contact details:
Dr Martin Dace
(address on application)
Ham, Richmond upon Thames TW10 - to contact me, please use the on-line form;
- or me.